Funding: The PLoS Medicine Editors are each paid a salary by the Public
Library of Science, and they wrote this editorial during their salaried time. No
specific funding was received for this paper.

Competing interests: The PLoS Medicine Editors' individual competing interests
are at http://www.plosmedicine.org/static/editorsInterests.action. PLoS
is funded partly through manuscript publication charges, but the PLoS
Medicine Editors are paid a fixed salary (their salary is not
linked to the number of papers published in the journal).

It has been a couple of months now since the withdrawal of access via HINARI to
medical journals in Bangladesh by several publishers caused an upset in the medical
publishing world [1]. HINARI (Health Internetwork Access to Research
Initiative) is a WHO-supported program [2] that partners with
subscription-based publishers to allow researchers in the world's poorest
countries to access some of their journals under certain conditions (for example,
researchers have to access the journal in defined institutions). After much lobbying
from researchers, editors, and others following the withdrawal, HINARI access has
been—for the time being at least—reinstated, though with a substantial
lack of clarity over the longer term plans of a number of the publishers [3]. Although
traumatic for the researchers who lost access, the incident has triggered a useful
debate on the value of open access (OA; immediate, permanent free access and
permanently guaranteed unrestricted reuse, as enshrined in a Creative Commons
license [4] and as
practiced by publishers such as PLoS) versus free access with no legal rights
attached. It is hard to think of a better example to demonstrate the precariousness
of this latter type of free access, which can mean that access may be withdrawn for
no reason.

Now that the heat of the HINARI debate has died down, it is an opportune time to
consider how this dispute, and others like it, can be used constructively to move
toward a position where universal OA to the medical literature becomes the norm.

On the positive side, the debate has brought many new voices into the discussion
around access, particularly those on the online discussion forum HIFA2015 [5], where the
diversity and strength of opinions expressed was most likely the key instrument in
ensuring that the publishers' withdrawal from HINARI was not only brought to
light, but also largely reversed.

The debacle also allowed constructive discussions around the substantial limitations
of HINARI and its inability to provide a long-term sustainable solution to access in
the developing world. It also allowed airing of many OA issues, including the
difference between free and open access [4]; the logistical difficulties
experienced by some researchers in accessing online journals, such as those in
locations with low bandwidth; the suspicion of some researchers of online-only
journals; and concerns over publication fees.

Thus the argument about how to implement such access, particularly in the developing
world, is far from over. The issues above are very familiar to OA advocates. When
PLoS Medicine was getting started seven years ago, we
encountered many of the same questions from the (admittedly mostly developed-world)
authors and readers we canvassed then. The phenomenal growth of OA since then has
reassured many of those who initially questioned the model and its sustainability:
submissions and publications are increasing each year at PLoS and in other
open-access journals, reflecting the increased confidence of authors in this model.
OA papers are also highly accessed, though our data suggest that most of this
access, and most of the authors, still come from the developed world.

The HINARI incident thus highlights the fact that HINARI is, sadly, still needed both
because of traditional publishers who have not yet implemented OA, even in the
developed world, and because substantial gaps remain in our knowledge about how OA
will work for the developing world. Hence, there is some way to go before this model
of publishing can become the norm worldwide. Despite the best intentions of
open-access publishers, we have failed to reach out adequately to debate with
researchers and readers in the less-developed world about the potential benefits of
open access. Instead, as is often the case when the developed world prescribes for
the less-developed world, we have assumed that what works well in Paris, London, or
San Francisco will work just as well in Addis Ababa, Beirut, or Lima.

Some examples of these active concerns about OA: first, are OA journals being
delivered in the best format for readers in the developing world? If print really is
better in some places, are we doing our best to ensure that the online journals are
optimized for rapid downloading and printing of articles? If access to online
journals will be primarily via mobile devices rather than computers, are we
delivering the content in appropriate formats? Second, do we understand the
reputation metrics outside of Europe or the US that will ensure that the new OA
journals are trusted and meet the requirements authors face for academic promotions
or other professional needs [6]? Even more importantly, are there OA journals available
that cater to the needs of readers and authors across the developing world? Should
publishers be helping groups to start their own journals, rather than assuming that
the existing OA journals will be accepted?

Medical journals have many roles, but, above all, dissemination of medical
information is key. This crucial role was stated clearly back in1997 by Neil
Pakenham-Walsh (the founder of HIFA2015) and colleagues, and it is no less relevant
now [7]:
“Providing access to reliable health information for health workers in
developing countries is potentially the single most cost effective and achievable
strategy for sustainable improvement in health care.”

Much therefore remains to be done in improving access to health information in the
developing world. By providing a logistical framework for open access (by the
adoption of appropriate licenses), and by showing what can be done in the developed
world with OA journals, OA publishers have done much to make it possible more
widely. The next crucial step is to engage with readers, researchers, and authors in
the developing world to understand better their information needs so that we
don't fall into the trap of pushing information in only one direction. Open
access is about facilitating the movement of knowledge—in all directions.

Author Contributions

Wrote the first draft of the editorial: VB. Contributed to the writing of the
editorial: JC SJ MN EV.